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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 0 0 <br /> ? 3 £ _ <br /> APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and ua <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. <br /> N G1 <br /> F//�ro <br /> a <br /> O=Print Contractor or Surveyor or Agent gE <br /> w 'm <br /> Ad ss Address `- <br /> &g'7&J/z/" 11IT <br /> City,State,ZiPtode � City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivision o $ <br /> v <br /> Structure Use: )nj 0 ° <br /> (family ho a/cabin, gar a type of addition, etc.) <br /> 03 <br /> Directions for plot plan drawing: <br /> 1.Show the location and size of all existing buildings(EB) and all new buildings(NB)and indicate North (N). <br /> 2.Show the location of the well (W),septic tank(ST), and drainfield (DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream - if within 300 ft. 0 <br /> 4.Show dimensions in feet of the following:(a)building to all lot lines,(b) building to center line of road,(c)building to ordi- <br /> nary high water mark of lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. O <br /> O <br /> 3 <br /> PLOT PLAN c a ` <br /> Z o <br /> o or <br /> m' <br /> � o <br /> ) o <br /> a 0 <br /> 0 <br /> N <br /> O <br /> 7 <br /> 7 <br /> O <br /> G Z <br /> �o <br /> (n 0 DDmy <br /> n c n nS. m <br /> �aM <br /> 9 S N O M Tj <br /> N O J O <br /> J <br /> N: m <br /> :A m <br /> �y o O <br /> o of C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. o <br /> N : <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> (sj at of owne ilding contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> o: o <br /> ° v n <br /> N N O N ��N <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 0 0 o m <br /> 000000041 <br />